Fun With Chemistry Camp    July 13 & 14, 2009    Application Form

 

Name _________________________________________________________________________

Home Address __________________________________________________________________

City ____________________________________  State __________________ Zip____________

Telephone No. (Home) ________________________  Grade Level  _______________________

Why do you want to attend Fun with Chemistry Camp 2009?  ______________________________

 _______________________________________________________________________________

_______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Parent/Guardian Name: ______________________________  Phone number _________________

Emergency phone number ________________________Name of contact ____________________

Name of Family Doctor: ___________________________   Phone number:  __________________

Allergies/medications taken: _________________________________________________________

Other medical information: __________________________________________________________

Please call Elizabeth Strong at (304) 277-2308 or e-mail strongli@westliberty.edu if you have any questions.

Please fill out form completely  and mail to:

Libby Strong
West Liberty State College SMART-Center
1610 Warwood Avenue 
Wheeling, WV 26003

Applications are due by July 9th, 2009...